Background
Methods
Study areas and populations
Kumasi | Bolgatanga | Jimma | Lilongwe | Ouagadougou |
---|---|---|---|---|
Population estimate: 1,529,151 | Total population of metropolitan Bolgatanga estimated at 147,729 | Population: 159,000 | Population: 24,000 | Population: 1.2 million (2006) |
Study conducted in Asokwa sub-metro with a population of 566,980 (2005), which is 30.3% of the Kumasi population | Study conducted in the urban town (population 72,768) | Study conducted in whole town | Study conducted in Kauma, a squatter settlement within urban Lilongwe | Study conducted in adjacent districts of Wemtenga and Taabtenga: two adjoining and contrasting neighbourhood. Wemtenga was subdivided, built up and serviced with all the urban amenities, while peripheral Taabtenga was not subdivided and had a rural appearance |
Malaria prevalence of 37% and accounts for over 45% out-patient cases | Malaria prevalence of 22%. Children < 5 years with uncomplicated malaria represented 29.5% of all reported cases in 2007 | The peak of malaria incidence follows the main rainfall season in July, August and September. Prevalence < = 4.9% in the population, but was 20.43% in < 5 year-olds (2006) | Malaria prevalence in < 5 s was 14% (2010 Lilongwe malaria survey) | Case morbidity in under 5 years in high transmission season is approximately 50% |
Children < 5 years and infants form 20% and 4%, respectively | Children < 5 years: 13% of the population | Children < 5 years: 9.2% of total population | Children < 5 years: 19% of the population | Children < 5 years: 18.8% of study population (1,970/10,500) |
Main occupations are trading and farming Cultivation of vegetables and other crops is common | Presence of urban farming in immediate peri-urban areas | Many houses have gardens (bananas, coffee, kitchen gardens, etc) | Most people earn a living through petty vending or working as unskilled labourers while others (30%) are unemployed | Main occupations are: In Wemtenga: Salaried and trading In Taabtenga: farming, pretty vending and working as unskilled labourers. |
Study design
Kumasi | Bolgatanga | Jimma | Lilongwe | Ouagadougou |
---|---|---|---|---|
35: 18 males and 17 females | 28: 18 females and 10 males | 92: 60 females and 32 males | 8: 2 males and 6 females | 36: 30 females and 6 males |
Selection criteria: ability to read and write; keep simple records; live in the community; trusted and willingness to volunteer |
Selection criteria:
Be stable; previous volunteer experience; considered responsible and reliable; have b asic education |
Selection criteria:
Member of Idir at least for last one year; willing to work voluntarily; available for at least 2 years; available most of the time; acceptable by the community | Selection criteria: Employees of the Ministry of Health. CMDs have secondary level education. Not resident in the community |
Selection criteria:
Resident; availability; ability to read and write French; acceptable to local people; accept to work for the community; and general interest of the community |
Main occupation:
Unemployed: 25% Petty trader: 25% Teacher/Social worker: 12.5% Artisan: 15% Local leaders: 10% |
Main occupation:
Drug shop owners: 35.7% Mason: 7.14% Petty traders 35.7% Farmers: 17.85% Retired nurse: 3.57% |
Main occupation:
Unemployed: 70% (housewife) Students: 12% Petty traders: 11% Daily labourers: 5% Retired: 2% |
Main occupation:
Full time employment as Ministry of Health CMDs |
Main occupation:
Unemployed: 54% (housewife) Petty traders: 11% Artisan: 17% worker: 12% Students: 6% |
Training:
Initial 5-day non-residential training. Monthly updates held in the first three months of the intervention and two-monthly updates |
Training:
2 weeks training, conducted by the Regional Health Training Unit incl. two days at the Regional Health Laboratory |
Training:
Three day training. Training conducted in Amharic |
Training:
6 weeks by MOH. Trained for two weeks on administering pre-packs: Week 1 theory and Week 2 practical |
Training:
Two day training conducted in each zone of the site. |
Supervision:
Fortnightly supervision by 2 members of the research team |
Supervision:
Weekly supervision, by 2 members of the research team, when data was collected from CMDs, plus monthly meeting of CMDs |
Supervision:
Monthly monitoring and supervision meetings were held. 10 supervisors (from Jimma Health Admin. Bureau, Jimma Zone Health Bureau and Jimma University Specialized Hospital) supervised the CMDs. |
Supervision:
Regular supervision (3 times weekly) by District Malaria Coordinator, plus monthly joint meetings held with community members, District Malaria Coordinator and research team |
Supervision:
Regular supervision of the each CMD by the Chief Nursing Officer of the health facility to which the CMD was attached |
Community medicine distributors (CMDs)
Sample size
Data collection methods
Qualitative methods
Medicines used in the studies
Kumasi | Bolgatanga | Jimma | Lilongwe | Ouagadougou |
---|---|---|---|---|
ACTs (AS/AQ) procured by the MOH | ACTs (AS/AQ) supplied by UNICEF | Jimma town health bureau procured ACTs (AL) from Oromiya Regional Health Bureau | ACTs (AL) supplied by MOH | ACTs supplied by WHO to MEG. 4334 units of ACTs (AL) then made available for sale and return to 21 public/private drug seller and CMDs |
All CMDs were given two week supplies | Weekly supervision for each CMD to supply and collect cases seen weekly | Stocks kept at Jimma Health Centre | The study team was responsible for maintaining stocks at the community at regular supervision meetings | Stocks were kept at CNRFP and CMDs were given supplies when needed |
ACTs sold at GH¢0.50 (US$0.455)* for preschool children and GH¢0.20 (US$0.182)* for infants | ACTS sold at GH¢0.15 (US$0.137)* | Treatment was free | Treatment was free | ACTs sold at 100 F CFA (US$0.23)** for children: 6 months-3 years and 150 F CFA (US$0.34)** for children: 3-5 years |
Medicines not used after two weeks were withdrawn as a quality control measure | Stock-out only for paracetamol | ACTs after expiry date not used, and withdrawn as quality control measure | Drug stocks were replenished on a monthly basis | Drug stocks were replenished on a monthly basis |
Supervision
Data analysis
Ethical approval
Results
Community medicine distributors in urban CCMm
Kumasi | Bolgatanga | Jimma | Lilongwe | Ouagadougou | Total | |
---|---|---|---|---|---|---|
Number of CMDs | 35 | 28 | 92 | 8 | 36 | 199 |
Total number of febrile children seen by CMDs (average per CMD) | 955 (27) | 1,363 (49) | 2,634 (29) | 2,131(266) | 1,918 (53) | 9,001 (45) |
Duration of Intervention Phase Ave. no. febrile children seen per month Ave. no. febrile children seen per CMD per month | 12 months 80 2.3 | 12 months 114 4 | 24 months 110 1.2 | 15 months 128 3.5 | ||
Number of children treated with ACTs - N (%) within 24 hrs - N (%) treated with the correct dose | 905 (94.8)** 577 (63.76) 890 (98.3) | 909 (66.7)* 278 (31%) 888 (97.7) | 1,211 (46)* 784 (64.6%) 1,206 (99.6) | 2,131 (100)** Not available 2,131 (100) | 1,818 (95%)** Not available 1,818 (100) | 6,974 1639 (54.2) 6933 (99.4) |
Perceptions and practice
Indicators | Kumasi | Bolgatanga | Jimma | Lilongwe | Ouagadougou | |||||
---|---|---|---|---|---|---|---|---|---|---|
Base (N = 1054) | End (N = 1000) | Base (N = 530) | End (N = 956) | Base (N = 823) | End (N = 2,307) | Base (N = 823) | End (N = 839) | Base (N = 625) | End (N = 798) | |
1. % knowledge of signs and symptoms of severe malaria
| ||||||||||
■ Vomiting | 3.8 | 42.7 | 9.9 | 3.9 | 59.4 | 24.9 | 12.8 | 61.5 | 36.8 | 46 |
■ Diarrhoea | 5.7 | 59.8 | 14.5 | 41.6 | 6.6 | 1.6 | 9 | 36.1 | 12.3 | 32 |
■ Loss of consciousness | 3.2 | 0.7 | 2.8 | 1.2 | - | - | 44.1 | 29.0 | 18.3 | 14 |
■ Convulsions | 8.0 | 4.3 | - | - | 65.6 | 34.8 | 43.3 | 59.2 | 22.0 | 31 |
■ Yellowness | 8.0 | 42.7 | - | - | - | - | 5.2 | 20.4 | 26.0 | 21 |
■ High body temperature | 50.7 | 71.7 | 35.5 | 14.9 | 96.2 | 85.5 | 0.7 | 2.6 | 70.2 | 95 |
■ Inability to feed/suckle | 11.6 | 22.2 | 4.5 | 4.8 | 44.0 | 33.2 | 27.5 | 69.7 | 25.0 | 55 |
■ Weakness | 40.0 | 0 | 43.8 | 32.1 | 5.6 | 6.1 | 10.5 | 18.6 | 26.0 | 27 |
■ Not passing urine | 1.1 | 34.2 | - | - | 0 | - | 22.0 | 53.4 | - | - |
■ Fast breathing | 16.8 | 23.7 | - | - | - | - | 17.4 | 20.7 | - | - |
■ Drowsy | 3.7 | 61.7 | - | - | - | - | 3.4 | 35.6 | 7.1 | - |
■ Don't know | 7.1 | - | - | - | - | 26.0 | 7.2 | - | - | |
■ Other | 14.0 | 0.9 | 1.5 | - | - | 0 | 3.2 | - | - | |
2. Preferred provider for childhood malaria treatment
|
(N =
1054)
|
(N =
1000)
|
(N =
930)
|
(N =
956)
|
(N = 823)
|
(N = 2305)
|
(N =
671)
|
(N =
839)
|
(N =
625)
|
(N =
798)
|
■ Self-treatment (herbs) | 0.0 | 0.0 | 30 | 0.6 | 0 | 0 | 6.6 | 3.0 | 29 | 13 |
■ Self Treatment (mod. med.) | 0.0 | 53.2 | - | 5.7 | 0.0 | 5.6 | 68.1 | 26.6 | - | 3.4 |
■ CMDs | 6.8 | 31.1 | - | 61.2 | 74.7 | 82.7 | 48.4 | 64.2 | 54 | 57 |
■ Public health facility | 9.2 | 0.0 | 47.18 | 28.2 | 24.2 | 10.8 | 21.6 | 93.9 | -- | -- |
■ Private clinics | 0.0 | 0.9 | 7.97 | 0.4 | 0.1 | 0.3 | 1.9 | 6.4 | 4 | 2 |
■ Traditional healers | 2.5 | 0.0 | 0.44 | 0.4 | 0.8 | 0.3 | 1.0 | 0.5 | 5 | 4 |
■ Informal medicine vendors | 3.1 | 24.3 | 10.52 | 0.8 | 0 | 0 | 47.5 | 5.1 | 23 | 29 |
■ Chemists/pharmacists | 4.8 | 2.0 | 3.65 | 2.7 | - | - | 0 | 1.5 |
-
|
-
|
Measures of performance
Indicators of treatment coverage
Kumasi | Bolgatanga | Jimma | Lilongwe | Ouagadougou | Total | |
---|---|---|---|---|---|---|
Total number of children with a fever episode in the previous 2 weeks identified at survey | 433 | 542 | 689 | 1238 | 798 | 3700 |
• Number (%) of caregivers who consulted the CMD | 179 (41.1) | 168 (31) | 50 (7.3) | 801 (64.7) | 282 (35.3) | 1480 (40) |
• Number (%) of children treated with ACTs from a CMD | 179 (100)** | 106 (63.) * | 32 (64)* | 801 (100)** | 95 (34) ** | 1213 (82) |
• Number (%) of children correctly treated (dose and duration) | 167 (93.1) | 53 (50) | 32 (100) | 798 (99, 6) | 73 (76) | 1123 (92.6) |
• Number (%) of children treated promptly (receiving first dose within24 hrs) | 123 (68, 7) | 37 (34.9) | 23 (71.9) | 590 (73, 7) | 55 (57.9) | 828 (68.3) |
• Number (%) of children treated correctly AND promptly | 123 (68, 7) | 37 (34.9) | 18 (56.3)/32 | 590 (73, 7) | 52 (54.7) | 820 (67.6) |
• Number (%) of mothers who did not find the CMD at the first attempt | 4 (2.2) | Not available | 7 (14) | Not available | 36 (12.7) |